A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Monitor oxygen saturation (SpO2) via continuous pulse oximetry.

Observe neck for jugular vein distention.

Notify healthcare provider to prepare for pericardiocentesis.

Assess for paradoxical blood pressure.

Answer and Explanation

The Correct Answer is C

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

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Free Nursing Study Resources

Correct Answer is []

Explanation

In an infant, a bulging fontanel is a classic sign of increased intracranial pressure. The fontanel, or soft spot on the top of the skull, can bulge when there is a buildup of pressure inside the skull, often due to conditions like hydrocephalus or complications with a ventriculoperitoneal shunt.

Preparing for a CT scan is crucial for diagnosing underlying causes of increased intracranial pressure, which could be related to shunt issues or other intracranial abnormalities.

Implementing seizure precautions ensures safety and readiness for possible seizures due to elevated intracranial pressure.

Monitoring pupil size helps assess neurological status and detect signs of increased intracranial pressure.

Tracking heart rate helps in identifying changes that may indicate deterioration in the infant’s condition related to increased intracranial pressure.

A. Weak urinary stream B. Fever C. Slow progression D. Urinary urgency E. Pain with urination

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,B"},"C":{"answers":"C"},"D":{"answers":"A,B,C"},"E":{"answers":"A,B"}}

Explanation

Weak urinary stream is most commonly associated with Benign Prostatic Hyperplasia (BPH) due to the enlarged prostate pressing on the urethra.

Fever can be a symptom of both Prostatitis and Urinary Tract Infection (UTI), as both conditions can involve an infection.

Slow progression of symptoms is typically associated with Benign Prostatic Hyperplasia (BPH), as it is a chronic condition that develops gradually over time.

Urinary urgency can be seen in all three conditions: Prostatitis, Urinary Tract Infection (UTI), and Benign Prostatic Hyperplasia (BPH), as all can cause irritation or obstruction in the urinary tract.

Pain with urination is a symptom of both Prostatitis and Urinary Tract Infection (UTI) due to inflammation and infection.

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A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Exhibits The nurse is considering the possible etiology of the client's symptoms. Click to indicate if the listed assessment findings are consistent with benign prostate hyperplasia, urinary tract infections, or prostatitis. Each column must have at least one response option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,B"},"C":{"answers":"C"},"D":{"answers":"A,B,C"},"E":{"answers":"A,B"}}

Explanation

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